INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 17 - 18, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Summit Medical Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on September 17, 2009.
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Plan of Correction
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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document clients were informed of the right to inspect their own records to include the project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client, in ten of ten client records.
The findings include:
Fifteen client records were reviewed on August 17 - 18, 2009. The facility informs clients of their rights by a client rights sign-off sheet. Ten records were required to include documentation that clients were informed of their client rights. The client rights sign off sheet did not inform clients that the project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and reasons for removing sections shall be documented and kept on file. The facility failed to inform clients of this right in client records # 3, 4, 6, 7, 8, 10, 11, 12, 13 and 14. On August 18, 2009, the facility director corrected this deficiency by posting an entire list of clients rights in the lobby of the facility.
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Plan of Correction
The Faciltiy Director made changes to both the Patient Rights form given to patients at intake and reviewed annually as well as the Patient Rights Form hanging in the front lobby. Changes made were to include the statement that not only do patients have a right to inspect their own records, but the project director may temporarily remove portions of the record prior to the inspection by the patient is the director determines that the information may be detrimental if presented to the patient.
As of this correction, the Patient Rights form given at intake and reviewed annually will reflect changes made by Facility Director. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of clients records, the facility failed to document a psychosocial evaluation that included a clinical assessment of client assets/strengths or other factors that can contribute to the resolution of identified problems, the potential or available client support systems, negative factors that might affect treatment, or the clients' preferred coping mechanisms in nine of ten client records.
The findings include:
Fifteen client records were reviewed on August 17 - 18, 2009. Ten client records required a psychosocial evaluation to include a clinical assessment of client assets/strengths or other factors that can contribute to the resolution of identified problems, the potential or available client support systems, negative factors that might affect treatment, or the clients' preferred coping mechanisms. Client records # 3, 4, 7, 8, 10, 11, 12, 13 and 14 did not include a clinical assessment of client assets/strengths, client support systems, negative factors that might affect treatment or the client's preferred coping mechanisms.
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Plan of Correction
As part of the staff meeting on 9/1/09, the Facility Director reviewed with all SMS staff the necessary changes that were to be required in the psychosocial evaluation from this point forward.
In the narrative section of this assessment, the fourth paragraph already is to be based on a counselor's prognosis of the patient's situation. It was reviewed that this paragraph will be expanded to give a more detailed explanation of the patients assets/strengths or other factors that can contribute to the resolution of identified problems, the potential or available patient support system, negative factors that might affect treatment, and the patient/s preferred coping mechanisms.
These changes will be monitored by the clinical supervisor by two methods. The clinical supervisor will check that these changes are being made upon data entry nto computer system (minimum one time a month). Also, peer reviews are completed upon each chart at least quarterly, and this is upervised by clinical supervisor. |